International Ayurvedic Medical Journal (IAMJ - Sep 2016) - An Ayurvedic approach to a case of movement disorder

AN AYURVEDIC APPROACH TO A CASE OF MOVEMENT DISORDERAmrithaEdayilliam Pady1, Dr. Muralidhara 2, Dr. Prashasth M J3,

Dr. Amarnath B.V.B 4

1PG scholar, 2Guide, MD (Ayu), HOD and Professor, 3Co-guide, MD (Ayu)Dept of PG studies in Kayachikitsa, 4MD (Ayu), Reader in Department of ShareeraRachana;

SKAMC& HRC, RGUHS Bangalore, Karnataka, India

INTRODUCTIONA rare case of 20-year-old female with in-voluntary movements (Chorea tic), ap-proached and was diagnosed as Sna-yugathavata and treated accordingly Pa-tient showed marked improvement inquality of life. This case is to understandhow to approach such cases on OPD andIPD level.Case study

A female patient aged 20 yearbelonging to lower middle class of Hindureligion, unmarried with an education of

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class presenting with Generalized involuntary movementssince 1 year.

Similar complaints since 15 days Associated with lip smacking, Pain over right lateral aspect of neck Nausea, reduced appetite, regurgitationof both liquid and solid food, constipatedstools (once in 3 days) and reduced urineoutput since 15 days.Patient was apparently normal 1 yearback, when patient suddenly developedgeneralized involuntary movement forwhich taken to physician and diagnosed ashyperkinetic movement disorder and wason medication since 1year before gettingadmitted at SKAMC Bangalore. 15 daysbefore the admission, in the morning, shesuddenly developed severe pain over right

Review Article International Ayurvedic Medical Journal ISSN:2320 5091

ABSTRACTChorea is a hyperkinetic movement disorder characterised by excessive spontaneous

that are irregularly timed, randomly distributed, quick, jerky, abrupt movements that involv-ing distal or proximal muscle group1. Chorea may be correlated to Snayugatavata comingunder the broad classification of vatavyadhi based on clinical features. Here is the case of20-year-old female presenting with involuntary movements. This particular study explainsabou t how an Ayurveda based approach and treatment starting from diagnosis improved thequality of life of the patient from poor family who was not able to afford costly diagnosisand treatment otherwise. Here we tried to assess the case based on the vikalpasamprap-thiand major involvement of vatadoshawas seen. Thus our focus on the diagnosis of thecondition was under the broad spectrum of vatavyadhi. This presentation is intended to ex-plain an approach based on Ayurvedic principles of diagnosis and management. Followingthe exclusion method of differential diagnosis, here reached to a probable diagnosis as Sna-yugatavata.Keywords:chorea, snayugatavata, vatavyadhi,vikalpasamprapti

How to cite this URL: Amritha Edayilliam Pady Et Al: An Ayurvedic Approach To A Case Of Movement Disorder.International Ayurvedic medical Journal {online} 2016 {cited 2016 July} Available from:http://www.iamj.in/posts/images/upload/2860_2865.pdf







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Amritha Edayilliam Pady Et Al: An Ayurvedic Approach To A Case Of Movement Disorder

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lateral aspect of neck followed by genera-lized irregular involuntary movementswhich was dominant over bilateral upperlimb, trunk and head, associated with lipsmacking unsteadiness and nausea.There was no loss of consciousness, frothysalivation, giddiness, vomiting or head-ache. Attack used to subside over a dayand used to recur on alternate days withincreased severity. Along with these com-plaints she had difficulty in swallowingfood (regurgitation of solid and liquidfood), reduced appetite, decreased fre-quency of urination and constipation. Onthe day of admission in SKAMC whilebrushing teeth she suddenly developedneck pain followed by involuntary move-ments and she fell down due to unsteadi-ness. At 10.00am they approached ourhospital for further management. Con-sciousness was preserved, no bowel andbladder incontinence during admission ofpatient.

Her appetite was reduced and de-creased urine output (once /day), hardconstipated stools (once in 3 days) withsound sleep (No involuntary movementswhile sleeping) since 15 days.

There was no h/o trauma, surgery,rheumatic fever, diabetes mellitus, dysli-pidemia. Her mother’s pregnancy was un-eventful and full term delivery from home.She had delay in developmental miles-tones such as- started walking at the age of8, slow unsteady walking, stooping for-wards and dysarthria since childhood.

Mild mental disabilities- such aspoor in school and academic work, diffi-culty in writing and reading, needs assis-tance for self-care such as eating, washingand bathing. She attained her menarche atthe age of 12, secondary amenorrhea sincethen (8 years). Her parents had consangui-neous marriage and having 6 siblings. Noone in the family said to have similar

complaints. She is on Tab sodium val-proate 200mg once daily since 1 year.Conclusion based on clinical examina-tion

Lean built, under nourished, pallor,and with coated tongue oriented to timeplace and person and intact memory,thoughts and perception.During the active phasePatient presented with altered appearance,behavior, and speech disturbances.Closure of bilateral eyes was not possible> 5 seconds along with difficulty in per-forming blowing of cheek.Complete protrusion of tongue was notpossible which was popping in and outrapidly along with involuntary movementsof tongue.Fast non rhythmic choric type of move-ment which was increasing with motoractivitypresented in bilateral upperlimb,head, trunk and less involvement of lower-limb with good muscle strength and poorpalmar and pincer grip.Knee jerk was exaggerated and plantarreflex was dorsiflexion.The analysis of case started in detail withthe help of dashavidhapareek-sha,amshaamshakalpana of doshadhathuinvolvement and nidanapanchakas. Theconclusionwas isVatavridhi, kapha, pi-thakshaya and dhathukshaya along with-vaikrutha in prana, udana, vyana,samana, apanavata karma, pachaka, sad-haka, alochakapitha vaikruthakarma,avalambaka, tharpaka, kaphavik-rutha karma is was present.SampraptiBeejadushti and madhuraharavihara leadto delayed developments of sensory andmotor property. Shareerikaand manasi-kanidanadoes further vataprakopa leadtokarshya, mamsashosha, shakrutgraha,indriyabramsha, arthavakshaya. Thesevikaras further aggravating vata lead to



udavartha. On other side aggravation vatavitiated Snayu ,sira, kandara lead to-shoola, aakshepaka, kampa.We came to a probable diagnosis of Sna-yugatavata.SamprapthighatakaDosha -VatapradhanatridoshaDooshy -mamsa, meda, majja, sirasnayuAgni -Jataragni, dhatvagniAma - SamavathaSrothas -medovahamajjavahaSrothodushtiprakara –Sanga, vimargagamanaUdbavasthana -pakwashayaVyakthasthana - sarvashareeraAdhishtana - sirasnayukandaraMarga - MadhyamaSadhyasadhyatha - AsadhyaPrevious investigational reportsReport of MRI on 18/6/2014: MRI of thebrain shows no definite abnormalityUSG abdomen on 18/6/2014: Featuressuggestive of cystitisRadiography of chest on 14/7/2014: Nor-mal chest x-rayHaematological test report on 18/6/2014Neutrophils -77%Lymphocytes-14.3%Ceruloplasmin serum-0.252Differential diagnosisFor understanding the disease well, fol-lowing differential diagnosis was consid-ered.Phakka roga2 Skandapasmara,3Vepathu4,Antharayama5, Akshepaka6, Thandava-roga7, snayugatavata8

As per modern science-Sydenham’s cho-rea, Wilson’s disease, Hyperthyroidism,ALS, Dystonia, Protein energy malnutri-tion, Global delay of development, Cho-reoathetoid cerebral palsy, Choreaoatheto-sis, Huntington's chorea8.Probable diagnosisSnayugatavata- akshepaka, antharayama.

ChoreoathetosisHuntington’s choreaTreatment Given On the day of admission started treat-

ment with Shirothalam withBramithaila+amlakichurna+jatamamsichurna for 7 days.

2nd day Sadhyavirechana with 30mlgandarvahastyadithailam+1/2 glass ofmilk in empty stomach.

Started sarvanga alepa chikitsa withteekshana lepa on the 3rd day of admis-sion for 5 days.

By the completion of 7 days of treat-ment in the hospital patient startedfeeling better. Choric movements re-duced 50%, athetoid movements waspresent, neck pain reduced to 60%, onVAS-5/10. Forward stooping whilewalking, standing was persistent. Re-duced appetite, not passing bowel mo-tions regularly, and micturition oncedaily were persisting.

On 8th day administered Virechanawith trivrut avaleha-30gm withtriphala kashaya 100ml as anupana at9.00am followed by discharge.

Condition on discharge- Patient had15 vegas of virechana

No involuntary movementsNo neck painAppetite was reduced, micturition wasonce daily.Adviced review on 11/8/15Discharge medicines- Mahapaishachikaghruta-3tsp-0-3tsp(before food)

Saraswatharishta- 3tsp-0-3tsp+6tsp water(before food) Cap sagarlic 1-0-1 before food.

On 13/8/15, patient approached opdfor follow up.Condition of the patient got better. Norecurrence of involuntary movements. Her



appetite got improved, and getting com-plete bowel motion regularly once daily,micturition was 4-5 times /day Adviced tila (sesame) in daily diet.

Cap sagarlic 1-0-1 before food Mahapaishachikaghrta 3tsp-0-3tspfor 1 month.

Assessment criteria9

Symptom Gradings

Handlingutensils

0 – normal1 -minimally impaired (difficulty with these tasks, but no helpneeded)2 - mildly impaired (occasional help needed)3 - moderately impaired (frequent help needed)4 - severely impaired (needs to be fed)

Hygiene 0 – normal1 -minimally impaired (difficulty with hygiene tasks, but nohelp needed)2 - mildly impaired (occasional help needed)3 - moderately impaired (frequent help needed)4 - severely impaired (completely dependent)

. Dressing 0 – normal1 -minimally impaired (difficulty with dressing, but no helpneeded)2 - mildly impaired (occasional help needed)3 - moderately impaired (frequent help needed)4 - severely impaired (completely dependent)

Walking 0 – normal1 - minimally impaired (walks with difficulty,but does not run into objects)2 - mildly impaired (walks with difficulty, running into objects)3 - moderately impaired (walks only with assistance)4 - severely impaired (chorea paralytica; cannot walk at all,even with assistance)

Involuntarymovement

0 – absent1 - minimal (action chorea, or intermittent rest chorea)2 - mild (continuous rest chorea, but without functional im-pairment)3 - moderate (continuous rest chorea with partial functional im-pairment)4 - severe (continuous rest chorea with complete functional im-pairment)

Tongueprotrusion

0 -can hold tongue protruded for more than 1 minute1 - can hold tongue protruded for more than 30 seconds2 - can hold tongue protruded for more than 10 seconds3 - can hold tongue protruded for less than 10 seconds4 - cannot protrude tongue



Bowelmovements

0- Once per day regular, without assistance with completeevacuation

1- Once in 2 days without assistance with incomplete evacua-tion

2- 2 times /week, with incomplete evacuation3- Less than once per week with assistance, incomplete

evacuation4- Less than once per week with digital assistance or enema.

Symptoms Before treatment After treatment

Handling utensils 3 2Hygiene 3 2Dressing 3 1Walking 3 1Involuntary movement 3 0Tongue protrusion 3 0Bowel movements 2 0DISCUSSIONChorea may affect any part of the bodybut is more common in the proximallimbs, neck, trunk, and facial muscles. Itmay be exacerbated by voluntary action,stress, and emotion. Chorea has manycauses. The most common causes of cho-rea in childhood include cerebral palsyand medication-induced and Sydenham’schorea. Choreiform movements in cere-bral palsy often begin in the third to fifthyear of life and may progress throughoutadolescence. Huntington’s disease inchildhood usually does not present withchorea but rather with intellectual andbehaviour changes, myoclonus, dystonia,and parkinsonian features. Choreiformcerebral palsy may be confused with be-nign hereditary chorea, an autosomaldominant disorder that may begin in in-fancy or early childhood and is associatedwith normal intellect10.Based on the vikalpasamprapti concludedunder vatavyadhi, probable diagnosis issnayugatavata. Since the patient frompoor economic status, not willing to givelab investigations we couldn’t do the con-

firmatory modern diagnosis. By consider-ing the presenting complaints, the prob-able diagnosis is chorea a movement dis-order. Here in this case by consideringthe saamavastha and avarana of vata, theinitial line of treatment we have adoptedwas Agnilepa which contains tulasi, ag-nimantha, nirgundi, haridra, lashuna,maricha, lavanga, sarshapa acts asaamapachana and srothoshodhana. Byconsidering both vatavrudhi and udavar-tha, started with thalam and sadhyovire-chanam to pacify the increased vata, foragnideepthi, and mala shodhana. Tostrengthen the body and improvebudhismruthivak prescribed mahpaisha-chikaghrutha and saraswatharishta. Tomaintain the patency and prevention ofsrothas and to keep apana vayu in nor-malcy lashuna in the form of Sagarliccapsule has been selected. Our nextconcentration is on her arthavapravruthi, we have put her onpithavrudhikara ahara. .Since vata wasvery much aggravated general principleof vatavyadhichikitsawas followed andtreated by looking into doshadooshyain-



volvement. Thus started observing thereduction in involuntary movements andable to improve the quality of life of thepatient.Vikaaraanam akushalo na jihriyaathkadaachanaNa hi sarvavikaaranaam naamato asthidruvaa sthithi11:REFERENCE1. Harrisons, Harrisons principle of in-

ternal medicine, 17th edition.2. VrddhaJivaka, VriddhajivakiyaTan-

tra, Vidyotini Hindi Commentary, by;Ayurvedalankar Sri SatyapalaBhisa-gacharya, Choukambha SanskritSansthan, Varanasi, reprint.

3. Sushruta, SushrutaSamhita, Niband-haSamgraha Commentary of Sri Dal-hanacharya and Nyaya Chandrika-Panjika Commentary of SriGayadasacharya, by; Vaidya YadavjiTrikramji Acharya, ChoukambhaS-urabharati Prakashan, Varanasi, re-print-2008, utharatantra 27th chapter

4. Madhavanidana, madhavacharya ,vathavyadhinidanamadhyaya, Chou-kambha Sanskrit Sansthan, Varanasi,reprint-2008

5. Agnivesha, CharakaSamhita, Ay-urveda Deepika Commentary ofChakrapani, edited by; VaidyaYadavji Trikramji Acharya, Chou-kambha Surabharati Prakashan, Vara-nasi, reprint-2011, Chikitsasthanachapter 28 .

6. Sushruta, Sushruta Samhita, Niband-haSamgraha Commentary of Sri Dal-hanacharya and Nyaya Chandrika-Panjika on Nidanasthana Commen-tary of Sri Gayadasacharya, by;Vaidya Yadavji Trikramji Acharya,Choukambha Surabharati Prakashan,Varanasi, reprint-2008

7. Bhavamishra, Bhavaprakasha, Vidyo-tini Commentary, edited by; Sri Hari-

hara Prasad Pandeyen and Pandit SriBrahmha Shankara Misra, Chou-kambha Sanskrit Bhawan, Varanasi.

8. Agnivesha, CharakaSamhita, Ay-urveda Deepika Commentary ofChakrapani, edited by; VaidyaYadavji Trikramji Acharya, Chou-kambha Surabharati Prakashan, Vara-nasi, reprint-2011, Chikitsasthanachapter 28 .

9. MD USCRS, UFMG Sydenham’schorea rating scale

10. Movement Disorders in Children:Definitions, Classifications, andGrading Systems Mauricio R.Delgado, MD; A. Leland Albright.

11. Vagbhata, Astanga Samgraha,Shashilekha Sanskrit commentary ofIndu, by; Dr Shivaprasad Sharma,Choukambha Sanskrit Series Office,Varanasi, reprint-2006, Sutrasthana12th chapter.

CORRESPONDING AUTHORAmrithaEdayilliam PadyPG Scholar Dept of PG studies in Kay-achikitsa, SKAMC& HRC, RGUHSBangalore, Karnataka, IndiaEmail:[email protected]

Source of Support: NilConflict of Interest: None Declared

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International Ayurvedic Medical Journal (IAMJ - Sep 2016) - An Ayurvedic approach to a case of movement disorder